PRP Injections

Good Morning,

I'm in need of cpt codes for Platelet Rich plasma Injections (PRP). The physicians have informed me that PRP is a concentrated platelet solution centrifuged from a patient's own blood sample. It contains a highly-concentrated solution of tissue growth factors, as well as platelets that stimulate the body to heal itself. Patient's come in and blood is drawn from the arm (anticubital spce) then centrifuged. The PRP is then injected into the area of treatment (mostly the knee). I appreciate any help...Thanks, Brenda

Oddly enough, I just came across this information this morning....Not sure if this will answer your question or applies to your situation.

CPTÂ® Assistant November 2005 Volume 15 issue 11
"Question: During an orthopedic procedure, 60 cc of the patientâ€™s blood was drawn and then centrifuged for 15 minutes to separate the PLATELET-rich PLASMA from the PLATELET-poor PLASMA. The red cells were injected into the operative site. What are the appropriate CPT codes to report for these procedures?

AMA Comment: The instillation of the PLATELETs by the surgeon into the surgical site would not warrant additional CPT code reporting as this is considered an integral part of the total procedure performed; therefore, the instillation is not separately reportable as there is no significant, additional physician work involved. However, code 86999, Unlisted transfusion medicine procedure, should be reported when blood is drawn intraoperatively from the patient and centrifuged to separate the PLATELET-rich from PLATELET-poor PLASMA and the red cells are injected into the operative site."

Autologous Tissue Graft

I'm not an expert, but I was recommeded to use 20999 (unlisted) or 20926, 38206 or for BC/BS S9055, but these codes are consider investigational procedures therefore may be denied by the insurance company. On the unlisted there are more chances to educated the carrier (w/C) and have them paid. There is a lot to do on the way the Doctors dictated the procedure.
I'll like to get other's opinion!
Madelin

This is just in as well:
This was just posted in the March 2009 CPT Assistant:

"Question: During an orthopedic procedure, the patient's blood was drawn and then centrifuged to separate the platelet-rich plasma from the platelet-poor plasma. The red cells were injected into the operative site. Is it appropriate to report code 36513, Therapeutic apheresis; for platelets, for the procedure performed to obtain the platelets?

Answer: No. To obtain the cells for injection, code 86999, Unlisted transfusion medicine procedure, should be reported when for example, intraoperatively, 60 ccsccâ€™s of blood are drawn from the patient, centrifuged for 15 minutes to separate the platelet-rich plasma (fibrin) from the platelet-poor plasma and red cells, and injected into the operative site. It is not appropriate to report code 36513 as therapeutic apheresis was not performed.

The placement/injection of the cells into the operative site is an inclusive component of the operative procedure performed and not separately reported, and would be considered an inclusive component of the operative procedure performed. "

Platelet Rich Plasma Injections
Since this has been an ongoing issue and there has been many comments regarding what codes, I paid for an official opinion from the AMA regarding how to report these injections when it is the ONLY thing being performed, since there is the 2005 CPT Assistant that talks about when done with surgical procedures. I just got the reply back:

My question was:
"PLATELET RICH plasma injections performed in the office for patients with muscle tears, meniscus tears, tendonitis and possibly other conditions and the only thing done, how should these be coded? Manufacturers are stating 20926 with 20550-20552 or 20610, and with 36513 or 36514 or 38230, and venipuncture, and with 86499 or 86940.

Reply:
...from a CPT coding perspective, whether performed in conjunction with a definitive surgical procedure or injected as indicated in your inquiry, there is no specific CPT code to describe PLATELET RICH plasma injection from the patient's blood, having been drawn and centrifuged, and injected into the anatomic site involved.
It would not be appropriate to report codes 20926, 20552, 20610 or codes 36513 or 36514 or 38230 to describe PLATELET RICH plasma injection from the patient's blood, having been drawn and centrifuged, and injected into the anatomic site involved. It is not appropriate to report code 86985 Splitting of blood or blood products, each unit to describe the derivation of the PLATELETs. Therefore, it is not appropriate to report code 86940.
According to the CPT Advisors representing the College of American Pathologists and the American Society for Clinical Pathology, code 86999 Unlisted transfusion medicine procedure, should be reported when for example, intraoperatively, 60 ccs of blood is drawn from the patient, centrifuged for 15 minutes to separate the PLATELET RICH [fibrin] from PLATELET poor plasma and red cells and injected into the operative site. "
In fact CPT and ICD-9 Coding Clinic have both stated that when performed during a surgical procedure there is NO additional professional service to report. However sales reps are giving these codes out inappropriately. Blood is not a (20926) paratendon, is not fat, is not dermis and is not a tissue graft - it is blood.
You are also not doing "Therapeutic apheresis" which below you will see what CPT states is involved in this process.

CPTÂ® Assistant November 2005 Volume 15 issue 11
"Question: During an orthopedic procedure, 60 cc of the patientâ€™s blood was drawn and then centrifuged for 15 minutes to separate the PLATELET-RICH PLASMA from the PLATELET-poor PLASMA. The red cells were injected into the operative site. What are the appropriate CPT codes to report for these procedures?

AMA Comment: The instillation of the PLATELETs by the surgeon into the surgical site would not warrant additional CPT code reporting as this is considered an integral part of the total procedure performed; therefore, the instillation is not separately reportable as there is no significant, additional physician work involved. However, code 86999, Unlisted transfusion medicine procedure, should be reported when blood is drawn intraoperatively from the patient and centrifuged to separate the PLATELET-RICH from PLATELET-poor PLASMA and the red cells are injected into the operative site."

CPTÂ® Assistant April 1996 Volume 6 Issue 4
"Understanding Apheresis

The primary reason peripheral blood stem cells are so clinically useful is due to the ease with which they are collected (from the bloodstream rather than from the bone marrow). Blood is collected from the patient through an intravenous catheter. By using a stem-cell protocol and any suitable blood cell separator method (eg, intermittent or continuous flow centrifugal technique, filtration technique), the desired circulating stem cells may be removed (cytapheresis). The remaining cells are returned (at that session) to the patient.

Current automated apheresis instruments use micro-processor technology for the following purposes: to administer an anticoagulant; to collect the treated blood; to separate components (either by centrifugation or by filtration); to isolate the desired component; and to recombine the remaining components for return to the patient or donor.

Over a 1-2 week period, a physician usually performs several 2-hour or 4-hour apheresis procedures on an inpatient or outpatient basis..."

ICD-9 Coding Clinic, Vol 19 No 2, 2nd Qtr 2002
"Question:
Our surgeons are now using PLASMA RICH PLATELETs to augment bone graft procedures. During the surgical procedure, a small sample (approximately 100 cc) of the patientâ€™s blood is drawn and placed into a disposable blood chamber(s) for processing in the Symphony PLATELET Concentrate System centrifuge. In the process, PLATELET poor PLASMA volume is removed from the blood samples. Approximately 10 ml of PLATELET RICH PLASMA (PRP) is procured. The surgeon conjugates the PLATELET concentrate with bone graft material and then applies the material to the wound site prior to closure. How should the procuring and application of the PRP via the automated processing system be coded or would this be considered a component of the bone graft procedure?

Answer:
Do not assign a unique code for the procuring or the application of the PLASMA RICH PLATELETs, since the use of the PLASMA is considered an integral part of the total procedure."

There is another 'hemostatis' product called Vitagel which is also not separately reported.

Orthopedic Coder's Pink Sheet
Effective Date 02/01/2008
Publish Date February 2008
Subject Reporting VITAGEL for Hemostasis
"Question: An orthopedic surgeon performed a total knee replacement. At the end of his report he wrote, â€śThe touniquet was deflated at this time. Hemostasis was carefully achieved with electrocautery. The knee was then thoroughly irrigated with antibiotic and saline solution. The VITAGEL tissue graft was then placed throughout the soft tissues to enhance hemostasis and the drain placed. The arthrotomy was closed...â€ť

Hereâ€™s my question: What code (if any) would be appropriate for reporting the VITAGEL? The doctor used CPT code 20926 (tissue grafts, other [e.g. paratenon, fat, dermis]) to code the VITAGEL as if itâ€™s a tissue graft. Everything Iâ€™ve read about VITAGEL is in regard to it being a product that assists the body in clotting the blood.

Answer: It would not be appropriate to bill 20926 or probably any other code for the VITAGEL application.

There are two reasons why 20926 would be inappropriate.

The AMA stipulates that the code is meant for obtaining the graft â€“ that is, harvesting it â€“ from another part of the body, not for applying an allographic tissue â€“ a substance from an outside source.
The graft codes, including 20926, should only be reported when the graft is obtained through a separate skin or fascial incision, the CPT manual states. So you would not be able to bill 20926 when â€“ as dictated here â€“ there is no additional incision made for the graft.
Hereâ€™s the full text of the graft coding rule, from the CPT manual: â€śCodes for obtaining autogenous bone, cartilage, tendon, fascia lata grafts, or other tissues through separate skin/fascial incisions should be reported separately unless the code descriptor references the harvesting of the graft or implant (eg, includes obtaining the graft).â€ť

Bottom line: VITAGEL is not separately billable. Hereâ€™s what First Coast Surgical Options, Medicare carrier for Florida and Connecticut , had to say in its January 2007 Medicare B Update:

â€śRecently, providers may have received instructions that may result in the incorrect billing of VITAGEL Surgical Hemostate using CPT code 20926 (tissue grafts, other [eg, paratenon, fat, dermis]). Hemostasis is considered to be an integral part of any surgical procedure. Therefore, VITAGEL Surgical Hemostat is not separately payable by the carrier and should not be billed using CPT code 20926.â€ť

Hi- What I am confused about and maybe I am reading to much into this, but when AMA states "However, code 86999, Unlisted transfusion medicine procedure, should be reported when blood is drawn intraoperatively from the patient and centrifuged to separate the PLATELET-rich from PLATELET-poor PLASMA and the red cells are injected into the operative site."

"Intraoperatively" so 86999 can be or can not be billed if done in office setting if patinet is preseting for (pain injection of knee)?

So in an office setting a patient with knee painthe doctor does PRP (20610 with 86999)? or 86999 with 99070?

Prp

PRP w adipose blood: can you bill for this procedure done in the office and what codes would you use?.........the patient was brought into the office for the following procedure (supraspinatus full thickness tear dx):.........extraction of adipose sites from his left abdomen, using a 16-gauge needle, a puncture hole was made into the abdomen a manual liposuction to extract about 15cc of adipose tissue, which also contained blood product. This mixture was then settled down and the blood products were extracted out, leaving about 7cc of adipose tissue containing mesenquimal stem cells. 30cc of venous blood was then taken from the patient's rt arm and that was placed into a centrifuge and 3cc of PRP concentrate was obtained. We then added the 3cc of PRP to the 7cc of adipose derived mesenquimal stem cells in a 10cc syringe. We then used a 14-gauge needle to place into the defect under ultrasound guidance. The 10cc of concentrate was put into the defect...........would this be 15877(liposuction) or 20926-52(graft), 36415(venipucture), 20550(injection)....any help would be greatly appreciated.

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